THE WEST AFRICAN LABORATORY RESPONSE
PRESENTATION AT THE PATHOLOGY IS GLOBAL SYMPOSIUM ROYAL COLLEGE OF PATHOLOGISTS LONDON ,UNITED KINGDOM BY SAHR MOSES GEVAO UNIVERSITY OF SIERRA LEONE 1 st NOVEMBER , 2016
OUTLINE OF PRESENTATION Origin ,spread and magnitude of Ebola Virus Disease (EVD) in West Africa Causes of spread of the virus Laboratory diagnosis at initial stage of epidemic EVD laboratories in West Africa during the epidemic Laboratory operations : diagnostic methods , coordination ,challenges and outcomes EVD sequencing and effects on control of the epidemic Studies on convalescent plasma therapy Bio banking and bio security Recommendations
ORIGIN, SPREAD AND MAGNITUDE OF THE EPIDEMIC The Ebola virus disease in West Africa has been the worst both in magnitude and geographical spread in history and was responsible for over 28,000 infections and 11,000 deaths. The initial cases were diagnosed in March 2014 in the Guckedou province in Guinea close to the boarders with Liberia and Sierra Leone. The virus spread to these neighboring countries by June 2016 reaching a peak in all geographical divisions by December 2014,
ORIGIN OF EVD OUTBREAK IN WEST AFRICA
COUNTRIES AFFECTED BY CURRENT EBOLA OUTBREAK Country Cases Deaths Last update On 16 September 2015 by WHO Liberia 10,672 4,808 Sierra Leone 13,756 3,953 Guinea 3,792 2,530 Nigeria 20 8 Mali 8 6 United States 4 1 Italy 1 0 United Kingdom 1 0 Senegal 1 0 Spain 1 0 as of 13 September 2015 Total 28,196 11,306
CAUSES OF RAPID SPREAD OF EBOLA IN WEST AFRICA Urban characteristics, population mobility Altered viral characteristics and clinical presentation Cultural practices and resistance Post conflict economic circumstances and social environment Home treatment of patients by health workers Limited infrastructure and disaster preparedness Insufficient human resource capacity
CAUSES OF RAPID SPREAD OF EBOLA IN WEST AFRICA Delayed community engagement and empowerment Lack of financial resources Ill defined coordination, communication and collaboration Limited laboratory capacity, infrastructure and equipment Late declaration by WHO of the international nature of epidemic Inadequate PPE and poor IPC practices by health workers
A COMPLEX EBOLA EPIDEMIC RESPONSE • Several key players including the governments and line ministries, who, the world bank, united nations agencies and other international agencies like DFID, local NGO and the local community. • Coordination of the response was undertaken by the national Ebola response centres. • The technical arm of the response was effected by different pillars. • Case management, psychosocial, surveillance, communications, safe burials, social mobilization, and the laboratory.
INITIAL EVD LABBORATORY DIAGNOSIS There was a paucity of laboratories capable of diagnosing Ebola virus disease in West Africa before the outbreak. The first case of Ebola in Guinea West Africa was diagnosed by a France on 23 rd of European mobile laboratory in located in March 2014. In Sierra Leone the first case was diagnosed in the Lassa fever laboratory which was established by Tulane university, USA about a decade prior to the EVD epidemic.
In Nigeria diagnosis was done within the first 24 hours at the virology department of the College of Medicine - University of Lagos. However, as the epidemic spread within the various countries, considerable difficulties emerged including transportation of samples on rugged roads from far away distances and a marked increase in the number of sample thus delaying the response due to prolonged turnaround times. The capacity of these laboratories in the most affected countries was soon outstretched with the rapidly advancing epidemic thus necessitating the deployment of several mobile laboratories countrywide to shorten the turnaround times and improve efficiency.
RUGGED ROADS IN EASTERN SIERRA LEONE
EVD Labs in Sierra Leone
OUTBREAK RESPONSE IN SIERRA LEONE 2014-2015 ( MAY) 10 Countries 16 INTERNATIONAL LABS Area Labs South Africa 1 Area Labs USA 2 WESTERN 9 Canada 2 EASTERN 1 Italy 2 NORTHERN 4 Germany 1 SOUTHERN 2 China 2 Netherlands 2 Nigeria 1 United Kingdom 3
There are small laboratories, designed specifically to handle viral haemorrhagic fever pathogens, with the capability to be deployed rapidly to the source of an outbreak. The equipment consists of one collapsible class three cabinet and two smart cyclers, which can all be transported on a normal commercial flight.
ROLE OF LABORATORY IN THE OUTBREAK 1. Diagnosis of suspected cases satisfying case definition. 2. Testing of all corpses during the epidemic 3. Testing prior to discharge 4. Genomic sequencing 5. Viral persistence studies 6. Convalescent blood/plasma studies
EBOLA VIRUS DISEASE CASE DEFINITION 1. Elevated by temperature or subjective fever or symptoms Severe headache Fatigue Muscle pain Vomiting Diahorroea Abdominal pain Unexplained haemorrage 2. An epidemiological risk factor twenty (21) days before onset of symptoms 3. Symptoms mimic cholera ,malaria typhoid, Lassa fever which are epidemic in West Africa
PATHOGENESIS OF EBOLA VIRUS DISEASE
• The laboratory plays a critical role in combating the Ebola virus disease. Laboratory results are required for vital decision making such as quarantine of households and communities, treatment and discharge of patients. • The work of these laboratories was facilitated by ensuring an efficient pre-analytical phase and post-analytical phase: collection, packaging and transport of samples and the dissemination of the result to various stake holders for action. • The laboratory technical working groups in the affected countries in collaboration with the visiting teams served as the laboratory pillar to devise strategies to ensure an efficient laboratory response, build on successes, solve mitigating factors and challenges.
• SPECIMEN MANAGEMENT PRE- • COLLECTION DIRECTION OF ANALYTICAL HOLDING and • PACKAGING Treatment unit • TRANSPORT CASE MANAGEMENT SURVEILLANCE/trend • TESTING LAB ALGORITHM • NICD ANALYTICAL • KERRYTOWN • CDC-USA • CDC-CHINA POST • RESULT DISSEMINATION ANALYTICAL
Laboratory Response Progress and Challenges 1 Response Activity Achieved Evidence CHALLENGES/GAPS Process Flow 1) Specimen -Develop specimen collection -Trained specimen -Limited cold chain Management stock list and distribution collectors and in remote regions. protocol. Laboratory Liaison Officers. -Lack of Bio-security -Develop human resource -National use of chain and Bio-risk policy. plan and conduct training for of custody. all 4 regions. -Mapping laboratory -Need Bio-Banking to facility to improve for specimen storage TAT. 2)Specimen -Engage RSLAF to support -Improved specimen -Timely Vehicular Transportation specimen courier. transit. maintenance. -Established travel routes. -Biosecurity of specimen. 3)Laboratory -Implement 2 rounds of -Participation in -Independent Testing Quality External QA WHO EQA PT Laboratory actions Assurance (QA) -Conduct 3 quality audits -Laboratory utilization on testing protocol. -Conduct 1 Transition audit of improved testing -Prioritisation of -Usage of National Malaria protocol. research studies. testing protocol. -Malaria Parasite -Shortage of local testing as part of personnel being management. trained.
Laboratory Response Progress and Challenges 2 Response Activity Achieved Evidence CHALLENGES/GAPS Process Flow 4) Result -Establishment of Laboratory -Harmonised reporting -Uncontrolled result Dissemination unit at Command Centre. result template. sharing breaching -Development of drop down -National leadership in patient result template. result analysis. confidentiality. -Development of result reporting 1 st loop to facility. 5) -Establishment of laboratory -Lab Coordinating -Limited support for Coordination Technical working group. centre OFFICE at NERC supportive Weekly technical team -Supportive supervision supervision. meetings to define training needs. -Need to review MOU -Coordination of training Phased closure of of laboratory -Development of laboratory laboratories in line with partners. transition to MOHS case management -Unilateral actions of -Linkage with case scaling down. laboratory partners. management on facility -National Transition operations plan developed in line -World Bank funding for with health sector plan laboratory services through and MRU initiatives. WHO.
TRAINING Human resource training plan were designed and rolled out nation wide with focus on reduction in rejection rates of samples collected and reduction of turn around times. Moreover there was an urgent need to implement infection, prevention and control, training and undertake monitoring and support supervision in order to reduce mortality amongst laboratory workers.
TRAINING OF SWABBERS DURING THE EBOLA EPIDEMIC
DOFFING AND DISPOSAL OF PPE
LABORATORY COORDINATION MEETING
OPENING CEREMONY: TRAINING OF RAPID RESPONSE TEAM
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